Provider Demographics
NPI:1669664009
Name:GOTTAM, CHETHANA CHANDRUPATLA (MD)
Entity Type:Individual
Prefix:DR
First Name:CHETHANA
Middle Name:CHANDRUPATLA
Last Name:GOTTAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CHETHANA
Other - Middle Name:
Other - Last Name:CHANDRUPATLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:43900 GARFIELD RD
Mailing Address - Street 2:STE 100
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1128
Mailing Address - Country:US
Mailing Address - Phone:586-286-0112
Mailing Address - Fax:586-286-2702
Practice Address - Street 1:28903 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072
Practice Address - Country:US
Practice Address - Phone:248-581-0333
Practice Address - Fax:248-876-9144
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME116448207N00000X
IL036.122055207N00000X
MI4301108548207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP50980022Medicare PIN